52 General Treatment Guidelines This chapter describes the key steps that I take for complication avoidance. Even so, complications do occur, so I also describe the less common but most helpful maneuvers I favor to minimize damage and regain control of the situation. The discussion is not comprehensive. Rather, I present my personal favorites. These pearls work well with my current technique, but I am always looking for new and better pearls. As in any human endeavor, a surgeon will benefit from skills that add to strengths and compensate for weaknesses. Read this chapter with an open mind, and try to identify elements that resonate with your own current technique and skill set. Some special steps in the preoperative evaluation help ensure a good surgical outcome. In addition to a comprehensive preoperative examination, including a dilated lens and fundus exam, the surgeon must evaluate the patient from the perspective of preparedness for surgery. Is the patient well oriented and able to cooperate? Do medical conditions, such as respiratory distress or spinal deformity, make supine positioning impossible? If topical anesthesia is being considered, does the patient exhibit a high level of anxiety, or squeeze uncontrollably during applanation pressure measurement? Before focusing on the slit-lamp exam, take a moment to look at the orbital configuration. Deep-set eyes, high orbital rims, or a narrow palpebral fissure all argue for a temporal incision. In the eagerness to examine the lens, do not forget to note the presence of blepharitis and to institute preoperative treatment. A history of epiphora may indicate lacrimal outflow obstruction and risk of infection; press on the lacrimal sac. Keratitis sicca has been linked to an ever more prominent role in interfering with accurate keratometry and A-Scan measurements for intraocular lens (IOL) power. The preoperative office visit is an excellent time to make note of this potential problem and institute treatment in an attempt to enhance preoperative measurement and postoperative outcomes. Corneal guttae must be carefully considered; if present, preoperative pachymetry and evaluation of cellular morphology are good indicators of endothelial function. Specular microscopy is helpful for both the diagnostic information it provides and from a medicolegal perspective. In any case, the patient needs to be informed of the increased risk of postoperative corneal decompensation and of the possibility of Descemet’s stripping automated endothelial keratoplasty (DSAEK) or Descemet’s membrane endothelial keratoplasty (DMEK). Additionally, the surgeon should put a prominent reminder in the admission note to be particularly vigilant, and take such steps as extra dispersive ophthalmic viscosurgical device (OVD), and low power in the bag phaco, to protect the depleted endothelium. The dilation of the pupil must be noted. Synechiae from prior surgery or inflammation need to be lysed at the beginning of the surgery. A poorly dilating pupil may mask the presence of underlying pseudoexfoliation, with the combined operative risks of poor dilation and potentially weak zonular support. If pseudoexfoliation material cannot be seen on the limited amount of visible anterior capsule, look carefully for pseudoexfoliation dandruff at the edge of the pupil and on the endothelium. Even if none is seen, the surgeon should note the potential in the admission note as a reminder to look carefully for pseudoexfoliation once the pupil is mechanically stretched at surgery. Preoperative accurate assessment of the cataract itself is very helpful in preparation for a smooth operative procedure. Use of the Lens Opacities Classification System (LOCS), devised by Leo T. Chylack, Jr. and coworkers,1,2 helps obtain consistent grading of the cataract and encourages a disciplined approach to lens evaluation. The published grading system was devised as a cataract research tool, but I keep a copy in each examination lane as a clinical guide. The key insight of the grading scheme is the separation of nuclear brunescence from nuclear opacification. Each of these aspects is graded on a scale of 1 to 6. Most clinicians pick up the habit in residency of simply glancing at a cataract and jotting down “3+ NS” for a moderately advanced senile cataract that is well along in nuclear sclerosis (hardening). Yet we cannot directly judge nuclear hardness at the slit lamp. A patient may complain of multiplopia and have progressive myopic shifting of the spectacle correction, with a modest amount of green-brown coloration but a high degree of haze in the central nucleus and less haze in the periphery. The rating would then be NC 2 (minimal color) and NO 5 (very significant opalescence). An elderly patient with 20/40 distance and J 1 near vision might have a dark brown but relatively clear lens, similar to the color of Coca-Cola. The rating might be NC 6 or NO 3. In both cases, the rating is much more meaningful than 2+ NS or 4+ NS, respectively. The first patient needs surgery; the second may not. The remainder of the LOCS classification deals with anterior (A) and posterior (P) opacities on a scale of 1 to 4. I have modified this to AC (anterior cortical), PC (posterior cortical), and PSC (posterior subcapsular) to differentiate these types of changes because PSC cataracts typically cause more glare symptoms. This rating system is not an empty exercise. In addition to sharpening the observations of the clinician, the ratings prepare the surgeon for the likely behavior of the nucleus during phacoemulsification. I use nuclear color and the patient age together to select which combinations of fluidics to employ. My phacoemulsification unit is programmed with five memory settings, and my admission note tells the operating room staff which memory setting to set up before I enter the room. This is both more efficient and safer than having the nurse ask, in mid-capsulorrhexis, “Is 200 OK?” Each surgeon needs to develop phaco memory settings appropriate for the technique and for the machine. For my high-vacuum phaco chop technique with the AMO Surgical Signature Unit (Abbott Medical Optics [AMO], Abbott Park, IL), each memory setting represents a 100 mm Hg increment in the high vacuum setting, with corresponding increases in maximum phaco power and intravenous (IV) pole height. In all cases, flow is set at 28 cc/min. For example, Memory 3 is 300 mm Hg vacuum, 80% maximum phaco power. I also add in a setting for WhiteStar™ (AMO) power modulations (micro-pulse phaco) and a setting for elliptical power. Each has its own vacuum and flow setting. Table 52.1 demonstrates the complexity of exploiting the settings for reliable outcomes. It lists the configurations used by William J. Fishkind, and demonstrates the complexity of the machine settings for one machine. Every machine, by virtue of its pump dynamics, software, tubing, foot pedal, venting, and tuning, will have distinctive settings. The optimum approach to define the settings that would be most advantageous to the surgeon is to work with the manufacturer’s surgical representative to fine-tune the settings. The admission note and the operative note are key elements that can defend you or damage you in the event of legal action. Accordingly, they should be fastidiously prepared to explain your plan and accurately convey the events of the surgery. Most importantly, the surgeon must use the admission note as a tool to maximize the potential for a complication-free surgery. The admission note is the surgeon’s opportunity to alert anesthesia and nursing personnel to key issues. These include the usual items such as medical allergies, systemic diseases, and medications, but also relevant issues such as anxiety, claustrophobia, back pain, tremors, language barriers, and many other factors that can have impact on the patient during surgery. As noted in the previous section on preoperative evaluation, the surgeon has many potential issues for which the admission note can be used as memory freshener. All of these elements should be typed in bold and, if particularly unusual or critical, bold italics. At the end of all my admission notes, after a statement of the risks that were reviewed with the patient, I list the preoperative keratometry and desired location of the wound, with the plan for astigmatic keratotomy if indicated; the IOL model and power; and the phaco memory setting. Any unusual elements (e.g., pseudoexfoliation or corneal guttae) are then reemphasized. This note can be placed in the operative chart, or even better, taped to the IV stand or the side of the phaco machine so that it can be consulted during the initial time out and at any time during the surgery (Fig. 52.1). The details of the standard operative procedure have been well covered in the preceding chapters. Individual surgeons will adopt the aspects that suit their technique. The most important principle is that a surgeon may be pleased with the current techniques and results, but should never be satisfied. The history of cataract surgery has proven that a highly successful procedure may always be improved. Often neglected are the aspects of surgery prior to the first incision that may well determine the success or failure of the procedure itself. This begins with the preoperative evaluation discussed previously, and continues with the preoperative care of the overall patient, which must result in a maximally relaxed, comfortable, and confident patient who is medically stable. At surgery, the patient must be positioned to be comfortable and simultaneously accessible to the surgeon. For example, the patient can be placed in the supine position, with one or two pillows under the knees to avoid lower back pain. The surgeon must take the time to examine overall patient positioning at the outset of the procedure. For example, to expose the superior cornea adequately, does the patient just need to be reminded to lift the chin, or should the headrest be adjusted or should the head pillow be removed? Reverse Trendelenburg positioning is helpful, as it facilitates the patient’s breathing by removing the pressure from the abdominal contents on the diaphragm. An important advance in cataract surgical access, in my opinion, has been the shift to temporal incisions. A superior incision requires rotation of the eye downward, with degradation of the optics, loss of red reflex, and often an arcus senilis or superior pannus obscuring the surgeon’s view. The temporal incision, in contrast, enables the eye to be positioned with a vertical optical access aligned with the operating microscope. A deep-set eye or prominent orbital rim no longer presents an obstacle. In setting up for surgery, the surgeon must observe the position of the operating microscope itself; the optical axis of the microscope must be precisely vertical if the eye is to be properly positioned (Fig. 52.2).
Preoperative Evaluation
Admission Note and Operative Note
Standard Operative Procedure
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